Preeclampsia-Eclampsia Adverse Outcomes Reduction: The Preeclampsia-Eclampsia Checklist
Abstract
:1. Introduction
2. Opportunity for Improvement
3. The Preeclampsia-Eclampsia Checklist
3.1. Checklist Development
3.2. The Preeclampsia-Eclampsia Checklist and Strengths
3.3. Checklist Effectiveness
3.4. Limitations of the Preeclampsia-Eclampsia Checklist
4. Preeclampsia-Eclampsia Checklist Implementation
Continuous Quality Improvement Assessment
5. Conclusions
Acknowledgments
Conflicts of Interest
Abbreviations
APACHE-IV | Acute physiology and chronic health evaluation version IV |
BMI | Body mass index |
CQI | Continuous quality improvement |
fullPIERS | Predictive model for maternal outcomes within 48 h of preeclampsia admission based on the pre-eclampsia integrated estimate of risk |
LMWH | Low molecular weight heparin |
MAP | Mean arterial blood pressure |
OR | Odds ratio |
PAPP-A | Maternal serum pregnancy-associated placental protein |
PDCA | Plan-do-check-act |
PDSA | Plan-do-study-act |
PE | Preeclampsia |
PE-E | Preeclampsia-eclampsia |
PIGF | Placental growth factor |
RRR | Relative risk reduction |
SGA | Small for gestational age |
SNAP-II | Simplified newborn illness severity and mortality risk scores |
UTPI | Maternal uterine artery doppler pulsatility index |
References
- Bartsch, E.; Park, A.L.; Kingdom, J.C.; Ray, J.G. Risk threshold for starting low dose aspirin in pregnancy to prevent preeclampsia: An opportunity at a low cost. PLoS ONE 2015, 10, e0116296. [Google Scholar] [CrossRef] [PubMed]
- Lowe, S.A.; Bowyer, L.; Lust, K.; McMahon, L.P.; Morton, M.R.; North, R.A.; Paech, M.J.; Said, J.M. The SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Aust. N. Z. J. Obstet. Gynaecol. 2015, 55, 11–16. [Google Scholar] [CrossRef] [PubMed]
- Sammar, D.; Syngelaki, A.; Sharabi-Nov, A.; Nicolaides, K.; Meiri, H. Can staining of damaged proteins in urine effectively predict preeclampsia? Fetal. Diagn. Ther. 2016. [Google Scholar] [CrossRef] [PubMed]
- Abalos, E.; Cuesta, C.; Grosso, A.L.; Chou, D.; Say, L. Global and regional estimates of preeclampsia and eclampsia: A systematic review. Eur. J. Obstet. Gynecol. Reprod. Biol. 2013, 170, 1–7. [Google Scholar] [CrossRef] [PubMed]
- Teela, K.C.; Ferguson, R.M.; Donnay, F.A.; Darmstadt, G.L. The PIERS trial: Hope for averting deaths from pre-eclampsia. Lancet 2011, 377, 185–186. [Google Scholar] [CrossRef]
- Martin, J.N., Jr. Severe systolic hypertension and the search for safer motherhood. Semin. Perinatol. 2016, 40, 119–123. [Google Scholar] [CrossRef] [PubMed]
- Pauli, J.M.; Repke, J.T. Preeclampsia: Short-term and long-term implications. Obstet. Gynecol. Clin. North Am. 2015, 42, 299–313. [Google Scholar] [CrossRef] [PubMed]
- United Nations. The millennium development goals report 2015. Available online: http://www.un.org/millenniumgoals/news.shtml (accessed on 29 February 2016).
- Main, E.K.; McCain, C.L.; Morton, C.H.; Holtby, S.; Lawton, E.S. Pregnancy-related mortality in California. Causes, characteristics, and improvement opportunities. Obstet. Gynecol. 2015, 125, 938–947. [Google Scholar] [CrossRef] [PubMed]
- Kaze, F.F.; Njukeng, F.A.; Kengne, A.P.; Ashuntantang, G.; Mbu, R.; Halle, M.P.; Asonganyi, T. Post-partum trend in blood pressure levels, renal function and proteinuria in women with severe preeclampsia and eclampsia in sub-Saharan Africa: A 6-months cohort study. BMC Pregnancy Childbirth 2014. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Nakimuli, A.; Chazara, O.; Byamugisha, J.; Elliott, A.M.; Kaleebu, P.; Mirembe, F.; Moffett, A. Pregnancy, parturition and preeclampsia in women of African ancestry. Am. J. Obstet. Gynecol. 2014, 210, 510–520. [Google Scholar] [CrossRef] [PubMed]
- Seys, D.; Wu, A.W.; Gerven, E.V.; Vieugels, A.; Euwema, M.; Panella, M.; Scott, S.D.; Conway, J.; Sermeus, W.; Vanhaecht, K. Health care professionals as second victims after adverse events: A systematic review. Eval. Health Prof. 2013, 36, 135–162. [Google Scholar] [CrossRef] [PubMed]
- Levy, B.S.; Mukherjee, D. Changes in obstetrics and gynecologic care healthcare triple aims: Moving women’s healthcare from volume to value. Clin. Obstet. Gynecol. 2015, 58, 355–361. [Google Scholar] [CrossRef] [PubMed]
- Roberge, S.; Demers, S.; Nicolaides, K.H.; Bureau, M.; Côté, S.; Bujold, E. Prevention of pre-eclampsia by low-molecular weight heparin in addition to aspirin: A meta-analysis. Ultrasound Obstet. Gynecol. 2016, 47, 548–553. [Google Scholar] [CrossRef] [PubMed]
- Acestor, N.; Goett, J.; Lee, A.; Herrick, T.M.; Engelbrecht, S.M.; Harner-Joy, C.M.; Howell, B.J.; Weigi, B.H. Towards biomarker-based tests that can facilitate decisions about prevention and management of preeclampsia in low-resource settings. Clin. Chem. Lab. Med. 2016, 54, 17–27. [Google Scholar] [CrossRef] [PubMed]
- Duley, L.; Gülmezoglu, A.M.; Henderson-Smart, D.J.; Chou, D. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia (Review). Cochrane Database Syst. Rev. 2010. [Google Scholar] [CrossRef]
- Goldenberg, R.L.; Jones, B.; Griffin, J.B.; Rouse, D.J.; Kamath-Rayne, B.D.; Trivedi, N.; McClure, E.M. Reducing maternal mortality from preeclampsia and eclampsia in low-resource countries — What should work? Acta Obstet. Gynecol. Scand. 2015, 94, 148–155. [Google Scholar] [CrossRef] [PubMed]
- Menzies, J.; Magee, L.A.; Li, J.; MacNab, Y.C.; Yin, R.; Stuart, H.; Baraly, B.; Lam, E.; Hamilton, T.; Lee, S.K.; et al. Instituting surveillance guidelines and adverse outcomes in preeclampsia. Obstet. Gynecol. 2007, 110, 121–127. [Google Scholar] [CrossRef] [PubMed]
- Royal College of Obstetricians & Gynaecologists. Run emergency obstetric skills and drills training. Available online: https://www.rcog.org.uk/en/careers-training/workplace-workforce-issues/improving-workplace-behaviours-dealing-with-undermining/undermining-toolkit/departmental-and-team-interventions/run-emergency-obstetric-skills-and-drills-training/ (accessed on 20 January 2016).
- Brown, J.P.; Zaya, C. Designing adult code simulations for antepartum and postpartum nurses. J. Obstet. Gynecol. Neonatal Nurs. 2013. [Google Scholar] [CrossRef]
- Ogburn, P. Obstetric Hemorrhage. Available online: https://www.health.ny.gov/professionals/protocols_and_guidelines/maternal_hemorrhage/docs/stony_brook_obstetric_hemorrhage_presentation.ppt (accessed on 8 August 2006).
- Sollecito, W.A.; Johnson, J.K. The global evolution of continuous quality improvement: From Japanese manufacturing to global health services. In McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care, 4th ed.; Sollecito, W.A., Johnson, J.K., Eds.; Jones & Bartlett Learning: Burlington, MA, USA, 2013; pp. 3–48. [Google Scholar]
- Barach, P.; Johnson, J.K. Assessing risk and harm in the clinical microsystem. In McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care, 4th ed.; Sollecito, W.A., Johnson, J.K., Eds.; Jones & Bartlett Learning: Burlington, MA, USA, 2013; pp. 249–274. [Google Scholar]
- Kelly, D.L.; Johnson, S.P.; Sollecito, W.A. Measurement, variation, and CQI tools. In McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care, 4th ed.; Sollecito, W.A., Johnson, J.K., Eds.; Jones & Bartlett Learning: Burlington, MA, USA, 2013; pp. 77–116. [Google Scholar]
- Dickson, K.E.; Kinney, M.V.; Moxon, S.G.; Ashton, J.; Zaka, N.; Simen-Kapeu, A.; Sharma, G.; Kerber, K.J.; Daelmans, B.; Gülmezoglu, A.M.; et al. Scaling up quality care for mothers and newborns around the time of birth: An overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy Childbirth 2015. [Google Scholar] [CrossRef] [PubMed]
- Nicolay, C.R.; Purkayastha, S.; Greenhalgh, A.; Benn, J.; Chaturvedi, S.; Phillips, N.; Darzi, A. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br. J. Surg. 2012, 99, 324–335. [Google Scholar] [CrossRef] [PubMed]
- Hagerman, N.S.; Varughese, A.M.; Kurth, C.D. Quality and safety in pediatric anesthesia: How can guidelines, checklists, and initiatives improve the outcome? Curr. Opin. Anesthesiol. 2014, 27, 323–329. [Google Scholar] [CrossRef] [PubMed]
- Moroz, L.A.; Simpson, L.L.; Rochelson, B. Management of severe hypertension in pregnancy. Semin. Perinatol. 2016, 40, 112–118. [Google Scholar] [CrossRef] [PubMed]
- Pucher, P.H.; Aggarwal, R.; Almond, M.H.; Darzi, A. Surgical care checklists to optimize patient care following postoperative complications. Am. J. Surg. 2015, 210, 517–525. [Google Scholar] [CrossRef] [PubMed]
- Jammer, I.; Ahmad, T.; Aldecoa, C.; Koulenti, D.; Goranović, T.; Grigoras, I.; Mazul-Sunko, B.; Matos, R.; Moreno, R.; Sigurdsson, G.H.; et al. Point prevalence of surgical checklist use in Europe: Relationship with hospital mortality. Br. J. Anaesth. 2015, 114, 801–807. [Google Scholar] [CrossRef] [PubMed]
- Mayer, E.K.; Sevdalis, N.; Rout, S.; Carls, J.; Russ, S.; Mansell, J.; Davies, R.; Skapinakis, P.; Vincent, C.; Athanasiou, T.; et al. Surgical checklist implementation project: The impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: A longitudinal study. Ann. Surg. 2016, 263, 58–63. [Google Scholar] [CrossRef] [PubMed]
- Arriga, A.F.; Bader, A.M.; Wong, J.M.; Lipsitz, S.R.; Berry, W.R.; Ziewacz, J.E.; Hepner, D.L.; Boorman, D.J.; Pozner, C.N.; Smink, D.S.; et al. Simulation-based trial of surgical-crisis checklists. N. Engl. J. Med. 2013, 368, 246–253. [Google Scholar] [CrossRef] [PubMed]
- Russ, S.J.; Sevdalis, N.; Moorthy, K.; Mayer, E.K.; Rout, S.; Caris, J.; Mansell, J.; Davies, R.; Vincent, C.; Darzi, A. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: Lessons from the “surgical checklist implementation project.”. Ann. Surg. 2015, 261, 81–91. [Google Scholar] [CrossRef] [PubMed]
- Browne, J.L.; van Nievelt, S.W.; Srofenyah, E.K.; Grobbee, D.E.; Klipstein-Grobusch, K. Criteria-based audit of quality of care to women with severe preeclampsia and eclampsia in a referral hospital in Accra, Ghana. PLoS ONE 2015, 10, e0125749. [Google Scholar] [CrossRef] [PubMed]
- Institute of Medicine. Weight Gain during Pregnancy: Reexamining the Guidelines; National Academies Press: Washington, DC, USA, 2009. [Google Scholar]
Reference | Rationale | Methodology | Outcomes | Results |
---|---|---|---|---|
[1] | Low-dose aspirin eligibility. | Mathematical modeling. | Minimum control event rate. Minimum event rate for treatment. Threshold number needed to treat. | Moderately-elevated-risk patients are eligible for low-dose aspirin. |
[2] | Management guidelines. | - | - | Synopsis of the 2014 Australia and New Zealand PE-E management guidelines. |
[3] | Congo red dot (CRD) urine test is a rapid, affordable diagnostic test. | Prospective cohort. | First, second, and third trimester PE detection. | In the first trimester CRD used alone detects 33.3%, 16.1%, and 20% of early, late, and all PE cases. |
[5] | Contextualizes significance of fullPIERS. | - | - | fullPIERS offers PE-E prediction. |
[6] | Historic context for maternal severe hypertension care bundle development. | Review article. | Vital signs changes. Systolic blood pressure (SBP), diastolic blood pressure (DBP). | Eclampsia alarm criteria: increases from pregnancy baseline––doubled maternal pulse pressure, SBP by 64 ± 12 mm Hg, or DBP by 31 ± 10 mm Hg. |
[7] | Historical context. | - | - | Defined early- and late-onset PE-E. |
[9] | California pregnancy-related deaths, 2002–2005. In the US in 1997, maternal mortality rate was 7.7/100,000 live births. By 2009 the rate increased to 17.8/100,000. | Retrospective cohort. | Leading causes of maternal mortality. | Cardiovascular disease, PE-E, hemorrhage, venous thromboembolism, and amniotic fluid embolism accounted for 143 of 207 pregnancy-related maternal deaths from 2002–2005. |
[13] | Relevance of continuous quality improvement in women’s healthcare. | - | - | Work with precursors, processes, and indicators to deliver better population health and better healthcare at lower cost. |
[14] | Combined antepartum low-dose aspirin and heparin. | Systematic review and meta-analysis. | Incidence of PE, severe PE, early-onset PE, and small for gestational age (SGA) fetuses. | In early-onset PE, low molecular weight heparin in combination with low-dose aspirin offers further reduction of PE and SGA fetuses than use of low-dose aspirin alone. |
[16] | Anticonvulsant efficacy for PE-E. | Systematic review of randomized trials of anticonvulsants with or without a placebo control group. | Eclampsia prevention. There was insufficient evidence to compare magnesium sulfate to diazepam, isosorbide, or methyldopa. | Risk of eclampsia is halved by magnesium sulfate, which is more effective than phenytoin and nimodipine. However, magnesium sulfate increases the risk of cesarean delivery when compared to phenytoin. |
[18] | Preeclampsia admitting diagnosis patients at a single-tertiary perinatal unit. | 24 month pre- and 41 month post-intervention cohort comparison. Intervention was a standardized surveillance protocol. | Any of 17 adverse maternal outcomes and any of seven adverse perinatal or infant outcomes. | Adverse maternal outcomes fell from 5.1% to 0.7%, Fisher p < 0.001, odds ratio 0.14, 95% confidence interval 0.04–0.49. Unchanged perinatal outcomes. |
[28] | Medical management of severe hypertension | - | - | Severe hypertension treatment protocol. |
Gestation | Signs and Symptoms | Actions | Severe Hypertension Protocol Applies at any Gestation | Postpartum Hemorrhage Protocol |
---|---|---|---|---|
Antepartum visit at 8–16 weeks gestation |
| If yes to any signs and symptoms:
| Systolic blood pressure (SBP)
≥160 mm Hg Or Diastolic blood pressure (DBP) ≥110 mm Hg for > 15 min. Administer
| Insert institution Postpartum Hemorrhage protocol here. Check for: Transfusion availability □ Platelets □ Fresh frozen plasma □ Cryoprecipitate □ Packed red blood cells Check for: □ Cell saver applicability |
Antepartum visit at 12–16 weeks gestation |
|
| Start hydralazine. Do not exceed 300 mg labetalol/24 h.
| Institute of Medicine
weight gain guide Pre-pregnancy Total BMI Weight gain lbs <18.5 28–40 18.5–24.9 25–35 25.0–29.9 15–25 ≥30.0 11–20 |
Antepartum visit after 16 weeks |
| If multiple gestation:
| Consultation per protocol.
| Second and Third Trimester Weight Gain Rate
BMI lbs/week <18.5–24.9 1.0 25–29.9 0.6 |
Before 24 weeks | □ Severe PE-E. |
| Short-acting is preferred.
| 1st Trimester Weight Gain All BMIs 1.1–4.4 lbs |
□ Excessive | Interval weight gain |
|
Gestation | Signs and Symptoms | Actions | Magnesium Sulfate Protocol | Initial Seizure Protocol |
---|---|---|---|---|
24–36 weeks | Symptomatic preeclampsia:
|
| Initial bolus 4–6 g in 100 mL normal saline iv. over 20 min.
Alternate im loading dose is 10 g in 50% solution total, as 5 g per buttock in 1–2 ml plain lidocaine:
|
|
Antepartum Admission |
| For hypermagnesemia Administer calcium gluconate 1 g as 10 ml of 10% solution iv over 1–2 min. | ||
Deliver if any of: |
| Immediate delivery. HELLP has a 6.3% maternal mortality, increased risk of placental abruption, and postpartum hemorrhage.
□ Administer magnesium sulfate for fetal neuroprotection, maternal blood pressure lowering, and seizure prophylaxis. □ Order peridelivery thromboprophylaxis □ Order PE-E blood and urine tests,
□ Order platelet transfusion if < 50 × 109 /L □ Order consultations: □ Neonatology □ Maternal-Fetal-Medicine | Eclampsia Rapid Response
| Recurrent Seizure Protocol □ Additional 2–4 g magnesium sulfate bolus over 10 min. |
Gestation | Action | |
---|---|---|
After 36 weeks | □ Immediate delivery. □ Administer magnesium sulfate for maternal blood pressure lowering, and seizure prophylaxis. □ Order PE-E blood and urine tests. □ Order pre-delivery fetal ultrasound including, □ complete biophysical profile □ umbilical artery dopplers. □ Request neonatology at delivery. | |
Post-delivery Day (PPD) 1 | □ Order PE-E blood tests. □ Continue magnesium sulfate for 24 h post-delivery. | |
Post-delivery Day (PPD) 2 | □ Order PE-E blood tests. Ambulate patient four times daily: □ PPD2 □ PPD3 □ PPD4 □PPD5 □ PPD6 Patient sits up in chair for meals: □ PPD2 □ PPD3 □ PPD4 □PPD5 □ PPD6 | |
Post-delivery Day (PPD) 7 | □ Order PE-E blood tests. Ambulate patient four times daily: □ PPD7 □ PPD8 □ PPD9 □PPD10 □ PPD11 Patient sits up in chair for meals: □ PPD7 □ PPD8 □ PPD9 □PPD10 □ PPD11 | |
Post-delivery Week 6 | □ Measure and record clinical blood pressure: ______/_____ □ Measure and record clinical weight: _______ □ Measure and record clinical height: ________ □ Record body mass index (BMI) : _______ □ First Line Intervention for BMI > 25 kg/m2. If Asian, BMI > 23 kg/m2. | First Line Intervention □ Specialist diet and activity history assessment □ Counseling referral to Registered Dietitian or Nutritionist. □ Exercise prescription and referral to Physical Trainer. |
Post-delivery Weeks 16–46 | Clinical blood pressure monitoring every 10 weeks. Record values: □ Week 16 □ Week 26 □ Week 36 □ Week 46 _____/____ ____/____ ____/____ ____/____ Clinical weight monitoring every 10 weeks. Record values: □ Week 16 □ Week 26 □ Week 36 □ Week 46 _________ _________ _________ ________ Clinical body mass index monitoring every 10 weeks. Record values: □ Week 16 □ Week 26 □ Week 36 □ Week 46 _________ _________ _________ _________ □ First Line Intervention for BMI > 25 kg/m2. If Asian, BMI > 23 kg/m2. □ Annual lipid panel and blood glucose. First Line Intervention if abnormal. |
Maternal Outcome Measures | Perinatal Outcome Measures |
---|---|
□ Maternal death □ Hepatic failure □ hepatic hematoma □ hepatic rupture □ Glasgow coma score < 13 □ Stroke | □ Stillbirth □ Neonatal death □ Infant death |
□ Two or more seizures □ Cortical blindness □ Positive inotrope support □ Myocardial infarction □ Third intravenous antihypertensive used □ Renal dialysis □ Renal transplantation □ 50% FIO2 for >1 h □ Pulmonary edema □ Pneumonia □ Intubation □ Postpartum hemorrhage. If checked choose: □ Medically managed □ Balloon tamponade □ Dilation and curettage □ Hysterectomy □ Uterine artery embolization □ Transfusion of 10 or more units of blood Products □ Intensive care unit admission Record highest BP mm Hg in first 24 h of admission: Systolic BP: _______ Diastolic BP:_______ Pulse pressure:_______ Mean arterial pressure:_______ Record history urine protein in first 24 h of admission: _______grams Record highest Aspartate transaminase in first 24 h of admission: ________ Record lowest platelet count in first 24 h of admission: ________ × 109/L □ Cesarean delivery. If checked choose all that apply for anesthesia: □ Spinal □ Epidural □ General □ Vaginal delivery □ Labor induction □ Length of labor □ Length of hospitalization | □ Bronchopulmonary dysplasia □ Necrotizing enterocolitis □ Grade III/IV intraventricular hemorrhage □ Cystic periventricular leukomalacia □ Stage 3–5 retinopathy of prematurity □ In special care nursery for more than 10 days: Record the number of days: ______days Record gestational age at delivery: _____weeks Record birth weight: _______grams □ Small for gestational age Record birth weight percentile _____ Record 0, 1, 5, and 10 min APGAR score _______, _______, ________, _______ |
© 2016 by the author; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Nwanodi, O.B. Preeclampsia-Eclampsia Adverse Outcomes Reduction: The Preeclampsia-Eclampsia Checklist. Healthcare 2016, 4, 26. https://doi.org/10.3390/healthcare4020026
Nwanodi OB. Preeclampsia-Eclampsia Adverse Outcomes Reduction: The Preeclampsia-Eclampsia Checklist. Healthcare. 2016; 4(2):26. https://doi.org/10.3390/healthcare4020026
Chicago/Turabian StyleNwanodi, Oroma B. 2016. "Preeclampsia-Eclampsia Adverse Outcomes Reduction: The Preeclampsia-Eclampsia Checklist" Healthcare 4, no. 2: 26. https://doi.org/10.3390/healthcare4020026
APA StyleNwanodi, O. B. (2016). Preeclampsia-Eclampsia Adverse Outcomes Reduction: The Preeclampsia-Eclampsia Checklist. Healthcare, 4(2), 26. https://doi.org/10.3390/healthcare4020026